Failure to Notify Physician and Family of Change in Condition for Two Residents
Penalty
Summary
The facility failed to notify responsible parties and physicians of significant changes in condition for two residents, resulting in delayed care and treatment. For one resident with a history of left femur fracture, diabetes, and recent hip surgery, a left heel wound initially identified as a blister progressed to a suspected deep tissue injury (SDTI) and later to an unstageable pressure injury with eschar, slough, and foul odor. Despite clear changes in the wound's appearance and the resident's increasing pain, the physician was not notified of the deterioration on the day it was observed. Documentation did not reflect timely communication or comprehensive wound assessments, and the resident was ultimately transferred to an acute care hospital for further evaluation and treatment after the wound worsened. Another resident, who lacked decision-making capacity and had a family member as the responsible party, developed right buttock redness that progressed to moisture-associated dermatitis (MASD), then to an unstageable pressure injury requiring debridement, and eventually to a stage four pressure injury. The family member was not informed of the initial skin changes or subsequent wound progression until the injury had reached stage four. Facility staff acknowledged that the family should have been notified at each stage of the wound's development, and the DON confirmed that both herself and the family member were not informed in a timely manner as required. Facility policies required prompt notification of physicians and responsible parties for changes in resident condition, as well as thorough documentation and escalation of wound care concerns. However, interviews and record reviews revealed that these protocols were not followed for either resident, resulting in a lack of timely intervention and communication regarding significant changes in their health status.